Seidel et al. The Journal of Headache and Pain (2017) 18:18 DOI 10.1186/s10194-017-0718-1
The Journal of Headache and Pain
SHORT REPORT
Open Access
Psychiatric comorbidities and photophobia in patients with migraine Stefan Seidel* , Roland Beisteiner, Maike Manecke, Tuna Stefan Aslan and Christian Wöber
Abstract Background: Based on recent findings and our own impressions we took a closer look at the relationship between (inter)ictal photophobia and psychometric variables in migraine patients with photophobia. Findings: For this study we included 29 (27 female) migraine patients and 31 (18 female) controls with a mean age of 31.6 ± 12.5 years and 24.0 ± 4.1 years, respectively. All participants filled out the Depression Anxiety Stress Scale (DASS). Interictal photophobia in patients was significantly higher than photophobia in controls (p = .001). Patients showed statistically significantly higher levels of depressive symptoms (p < .001), anxiety symptoms (p < .001) and stress (p < .001) than controls. Among all participants, (interictal) photophobia correlated positively with age (rho = .318, p = .013) as well as with the levels of depressive symptoms (rho = .459, p < .001), anxiety symptoms (rho = .346, p = .008) and stress (rho = .368, p = .005), but not with gender. In the patients, ictal photophobia correlated positively with age (rho = .473, p = .01) and interictal photophobia (rho = .423, p = .022). Linear regression analysis revealed only a trend towards statistical significance for (interictal) photophobia as a predictor for the level of depressive symptoms (rho = .457, p = 0.056) in the whole sample. Conclusions: Considering higher levels of photophobia in depression and the comorbidity of migraine and depression, it might be possible that depression contributes to interictal photophobia in patients with migraine. The same may be true for anxiety and stress. Both are also related to migraine and their possible impact on photophobia in migraine may be explained by pupillary dysfunction. Keywords: Migraine, Photophobia, Depression, Anxiety, Stress
Introduction Photophobia is a common symptom of migraine attacks experienced by up to 80% of the patients. The prevalence seems to increase with age [1–3]. Sensitivity to light is not limited to the headache phase, but frequently is also present in the premonitory phase as well as after headache has subsided [1]. Measuring quantitative thresholds for discomfort and pain with monocular and binocular light stimuli, Vanagaite et al. [4] found that migraine patients were more photophobic during attacks than outside attacks and that they were more sensitive to light than controls even between attacks. Main et al. [5] reported significantly lower interictal light discomfort thresholds in migraineurs compared to controls. Functional neuroimaging showed more activation of the * Correspondence: [email protected] Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
extrastriate visual cortex in migraine patients with photophobia compared to those without photophobia during the premonitory phase of a migraine attack [6, 7]. The comorbidity of migraine with depression, anxiety and stress is well known and was investigated recently in a population-based study by Risal et al. which highlighted the negative consequences of these comorbidities on the quality of life in migraine patients [8]. In this context it appears noteworthy that patients with psychiatric disorders often exhibit affective temperament dysregulation and suicidal behaviors [9]. These specific characteristics may significantly contribute to the psychocial impairment and altered quality of life of these subjects. A possible relation between depression and photophobia has been reported already in 1989 [10]. Recently Llop et al. [11] and Anagnostou et al. [12] investigated the association of migraine and photophobia. While the former authors [11] found that photophobia
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Seidel et al. The Journal of Headache and Pain (2017) 18:18
might predispose migraineurs for psychiatric comorbidities, the latter showed that photophobia may not exclusively be related to migraine [12]. During the patient recruitment for a case-control functional magnetic resonance imaging (fMRI) study on the effects of repeated flicker light exposure on photophobia in migraine patients (KLI 455, Austrian Science Fund, FWF) we noticed that the number of patients with significant psychiatric comorbidities exceeded our expectations. Hence, we decided to take a closer look at the relationship between (inter)ictal photophobia and psychometric variables in the subjects screened for participation in our fMRI study.
Findings We included patients with migraine and migraine-free controls screened for possible participation in a prospective study on the effects of repeated flicker light exposure on the level of photophobia (KLI 455, Austrian Science Funds (FWF)). The participants’ age had to be between 18 to 45 years. Inclusion criteria for patients comprised (1) migraine without aura according to the criteria of the beta-version of the third edition of the International Classification of Headache Disorders (ICHD-3 beta) [13], (2) 1–4 days with migraine per month in the 3 months preceding study inclusion, (3) an intensity of interictal photophobia of 2–6 on a numeric rating scale (NRS, range 0 to 10) and (4) an intensity of ictal photophobia of >4. Controls had to fulfil the following inclusion criteria: (1) no personal or family history of migraine and (2) photophobia 4 28 patients. Ten controls gave photophobia ≥2. Interictal photophobia in patients was significantly higher than photophobia in controls (Table 1, p = .001). Patients and controls also differed statistically significantly regarding their levels of depressive symptoms (p < .001), anxiety symptoms (p < .001) and stress (p < .001) on the DASS (Table 1). To further evaluate the impact of photophobia we performed multivariate correlation analyses including age, gender and DASS scores of depressive symptoms, anxiety symptoms and stress as well as linear regression analyses using each of the three psychiatric domains as dependent variables. Both calculations were done for the entire sample of participants (n = 60) and separately for patients with migraine (n = 29) and controls (n = 31). Among all participants, (interictal) photophobia correlated positively with age (rho = .318, p = .013) as well as with the DASS subscores for depressive symptoms (rho = .459, p < .001), anxiety symptoms (rho = .346, p = .008) and stress (rho = .368, p = .005), but not with gender. In the patients, the only statistically significant correlations were those of ictal photophobia with age (rho = .473, p = .01) and interictal photophobia (rho = .423, p = .022). Ictal photophobia did not correlate with gender and DASS scores. Interictal photophobia did not show any statistically significant correlations in patients and the same was true for photophobia in controls. Linear regression analysis revealed only a trend towards statistical significance for (interictal) photophobia as a predictor for the level of depressive symptoms (rho = .457, p = 0.056) in the whole sample. In separate analyses of patients and controls, none of the factors age, gender, (interictal) photophobia and ictal photophobia (for migraine patients only) significantly predicted the levels of depressive symptoms, anxiety symptoms and stress.
Discussion This analysis of 60 subjects screened for participation in a prospective study on the effects of repeated flicker light exposure on the level of photophobia revealed a trend towards a relation of photophobia to the severity of depressive symptoms, anxiety symptoms and stress.
Seidel et al. The Journal of Headache and Pain (2017) 18:18
Page 3 of 4
Table 1 Clinical data of migraine patients and controls Patients (n = 29)
Controls (n = 31)
p-value
mean ± SD
31.6 ± 12.5
24.0 ± 4.1
.74
range
19–68
20–29
Gender (m:f)
n
2:27
12:18
.005*
(Interictal) photophobia (NRS)
mean ± SD
3.1 ± 2.1
1.5 ± 1.8
.001+
range
0–8
0–7
Ictal photophobia (NRS)
mean ± SD
7.3 ± 1.8
N/A
range
3–7
N/A
DASS depression score
mean ± SD
3.6 ± 4.0
0.7 ± 1.1
range
0–15
0–5
DASS anxiety score
mean ± SD
4.0 ± 4.0
0.4 ± 0.8
range
0–14
0–3
DASS stress sore
mean ± SD
6.0 ± 5.2
1.4 ± 1.9
range
0–19
0–7
Age
–
The Journal of Headache and Pain
SHORT REPORT
Open Access
Psychiatric comorbidities and photophobia in patients with migraine Stefan Seidel* , Roland Beisteiner, Maike Manecke, Tuna Stefan Aslan and Christian Wöber
Abstract Background: Based on recent findings and our own impressions we took a closer look at the relationship between (inter)ictal photophobia and psychometric variables in migraine patients with photophobia. Findings: For this study we included 29 (27 female) migraine patients and 31 (18 female) controls with a mean age of 31.6 ± 12.5 years and 24.0 ± 4.1 years, respectively. All participants filled out the Depression Anxiety Stress Scale (DASS). Interictal photophobia in patients was significantly higher than photophobia in controls (p = .001). Patients showed statistically significantly higher levels of depressive symptoms (p < .001), anxiety symptoms (p < .001) and stress (p < .001) than controls. Among all participants, (interictal) photophobia correlated positively with age (rho = .318, p = .013) as well as with the levels of depressive symptoms (rho = .459, p < .001), anxiety symptoms (rho = .346, p = .008) and stress (rho = .368, p = .005), but not with gender. In the patients, ictal photophobia correlated positively with age (rho = .473, p = .01) and interictal photophobia (rho = .423, p = .022). Linear regression analysis revealed only a trend towards statistical significance for (interictal) photophobia as a predictor for the level of depressive symptoms (rho = .457, p = 0.056) in the whole sample. Conclusions: Considering higher levels of photophobia in depression and the comorbidity of migraine and depression, it might be possible that depression contributes to interictal photophobia in patients with migraine. The same may be true for anxiety and stress. Both are also related to migraine and their possible impact on photophobia in migraine may be explained by pupillary dysfunction. Keywords: Migraine, Photophobia, Depression, Anxiety, Stress
Introduction Photophobia is a common symptom of migraine attacks experienced by up to 80% of the patients. The prevalence seems to increase with age [1–3]. Sensitivity to light is not limited to the headache phase, but frequently is also present in the premonitory phase as well as after headache has subsided [1]. Measuring quantitative thresholds for discomfort and pain with monocular and binocular light stimuli, Vanagaite et al. [4] found that migraine patients were more photophobic during attacks than outside attacks and that they were more sensitive to light than controls even between attacks. Main et al. [5] reported significantly lower interictal light discomfort thresholds in migraineurs compared to controls. Functional neuroimaging showed more activation of the * Correspondence: [email protected] Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
extrastriate visual cortex in migraine patients with photophobia compared to those without photophobia during the premonitory phase of a migraine attack [6, 7]. The comorbidity of migraine with depression, anxiety and stress is well known and was investigated recently in a population-based study by Risal et al. which highlighted the negative consequences of these comorbidities on the quality of life in migraine patients [8]. In this context it appears noteworthy that patients with psychiatric disorders often exhibit affective temperament dysregulation and suicidal behaviors [9]. These specific characteristics may significantly contribute to the psychocial impairment and altered quality of life of these subjects. A possible relation between depression and photophobia has been reported already in 1989 [10]. Recently Llop et al. [11] and Anagnostou et al. [12] investigated the association of migraine and photophobia. While the former authors [11] found that photophobia
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Seidel et al. The Journal of Headache and Pain (2017) 18:18
might predispose migraineurs for psychiatric comorbidities, the latter showed that photophobia may not exclusively be related to migraine [12]. During the patient recruitment for a case-control functional magnetic resonance imaging (fMRI) study on the effects of repeated flicker light exposure on photophobia in migraine patients (KLI 455, Austrian Science Fund, FWF) we noticed that the number of patients with significant psychiatric comorbidities exceeded our expectations. Hence, we decided to take a closer look at the relationship between (inter)ictal photophobia and psychometric variables in the subjects screened for participation in our fMRI study.
Findings We included patients with migraine and migraine-free controls screened for possible participation in a prospective study on the effects of repeated flicker light exposure on the level of photophobia (KLI 455, Austrian Science Funds (FWF)). The participants’ age had to be between 18 to 45 years. Inclusion criteria for patients comprised (1) migraine without aura according to the criteria of the beta-version of the third edition of the International Classification of Headache Disorders (ICHD-3 beta) [13], (2) 1–4 days with migraine per month in the 3 months preceding study inclusion, (3) an intensity of interictal photophobia of 2–6 on a numeric rating scale (NRS, range 0 to 10) and (4) an intensity of ictal photophobia of >4. Controls had to fulfil the following inclusion criteria: (1) no personal or family history of migraine and (2) photophobia 4 28 patients. Ten controls gave photophobia ≥2. Interictal photophobia in patients was significantly higher than photophobia in controls (Table 1, p = .001). Patients and controls also differed statistically significantly regarding their levels of depressive symptoms (p < .001), anxiety symptoms (p < .001) and stress (p < .001) on the DASS (Table 1). To further evaluate the impact of photophobia we performed multivariate correlation analyses including age, gender and DASS scores of depressive symptoms, anxiety symptoms and stress as well as linear regression analyses using each of the three psychiatric domains as dependent variables. Both calculations were done for the entire sample of participants (n = 60) and separately for patients with migraine (n = 29) and controls (n = 31). Among all participants, (interictal) photophobia correlated positively with age (rho = .318, p = .013) as well as with the DASS subscores for depressive symptoms (rho = .459, p < .001), anxiety symptoms (rho = .346, p = .008) and stress (rho = .368, p = .005), but not with gender. In the patients, the only statistically significant correlations were those of ictal photophobia with age (rho = .473, p = .01) and interictal photophobia (rho = .423, p = .022). Ictal photophobia did not correlate with gender and DASS scores. Interictal photophobia did not show any statistically significant correlations in patients and the same was true for photophobia in controls. Linear regression analysis revealed only a trend towards statistical significance for (interictal) photophobia as a predictor for the level of depressive symptoms (rho = .457, p = 0.056) in the whole sample. In separate analyses of patients and controls, none of the factors age, gender, (interictal) photophobia and ictal photophobia (for migraine patients only) significantly predicted the levels of depressive symptoms, anxiety symptoms and stress.
Discussion This analysis of 60 subjects screened for participation in a prospective study on the effects of repeated flicker light exposure on the level of photophobia revealed a trend towards a relation of photophobia to the severity of depressive symptoms, anxiety symptoms and stress.
Seidel et al. The Journal of Headache and Pain (2017) 18:18
Page 3 of 4
Table 1 Clinical data of migraine patients and controls Patients (n = 29)
Controls (n = 31)
p-value
mean ± SD
31.6 ± 12.5
24.0 ± 4.1
.74
range
19–68
20–29
Gender (m:f)
n
2:27
12:18
.005*
(Interictal) photophobia (NRS)
mean ± SD
3.1 ± 2.1
1.5 ± 1.8
.001+
range
0–8
0–7
Ictal photophobia (NRS)
mean ± SD
7.3 ± 1.8
N/A
range
3–7
N/A
DASS depression score
mean ± SD
3.6 ± 4.0
0.7 ± 1.1
range
0–15
0–5
DASS anxiety score
mean ± SD
4.0 ± 4.0
0.4 ± 0.8
range
0–14
0–3
DASS stress sore
mean ± SD
6.0 ± 5.2
1.4 ± 1.9
range
0–19
0–7
Age
–
